Hospital, Medical, Dental And Optometric Service Corporations - Domestic 2000 Annual Statement Filings Worksheet - Arizona Department Of Insurance
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1Department of Insurance
ATTENTION:
State of Arizona
ANNUAL STATEMENT PREPARER
Financial Affairs Division
THE NAME AND NAIC # OF INSURER MUST
2910 North 44th Street, Second Floor
BE ON ALL FORMS FILED WITH ADOI
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420/Fax: (602) 912-8421
Hospital, Medical, Dental and Optometric Service Corporations - Domestic
2000 Annual Statement Filings Worksheet
NAIC:
COMPANY:
DOMICILE: AZ
Enter Company Figures Here
Enter Company Figures Here
↓
↓
↓
↓
↓
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Assets:
Arizona Direct Premiums:
(Page 2, Line 20, Col. 4)
(Page 68, Line 3, Col. 3)
Liabilities:
Reinsurance Assumed:
(Page 3, Line 15, Col. 1)
(Page 68, Line 91, Col. 3)
Total Reserves and Unassigned
Number of Arizona Enrollees (participants):
Funds:
(Page 15, Line 6, Col. 9)
(Page 3, Line 20, Col. 1)
Initial if
Initial at left if items are enclosed with 2000 Annual Statement
Agency
Enclosed
Use Only
↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
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_______
A.
Annual Report – One 8-1/2" X 14" (WHITE JACKET, SECURELY BOUND in two-sided book form)..........
_________
MUST INCLUDE TO BE COMPLETE:
_______
1. Jurat Page ......................................................................................................................................................
_______
a. Two Authorized Original Signatures ........................................................................................................
(SIGNERS NAMES MUST BE LISTED ON THE 2000 JURAT PAGE)
_______
b. Notarized Signatures ...............................................................................................................................
2. Actuarial Certification **NOTE: If Reserves = ZERO MUST ENTER N/A in box → → → →
** _____
.......
_________
ATTACH THE FOLLOWING REPORT TO THIS WORKSHEET:
_______
B.
Supplemental Compensation Exhibit ..................................................................................................................
_________
_______
C.
Copy of Managed Care Organizations RBC Formula Computation report. (See Form E-HMDO.I, item 4C)....
_________
_______
D.
Management Discussion & Analysis with Transmittal Form E-MDA (if available and enclosed) .....................
_________
The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without
report attached.
INITIAL TO CONFIRM THAT THE FOLLOWING REPORTS HAVE BEEN OR WILL BE SENT UNDER
SEPARATE MAILING TO ATTENTION: LIFE AND HEALTH DIVISION. DO NOT MAIL IN ANNUAL
STATEMENT ENVELOPE.
_______
E.
HIPAA-3/1, HIPAA-I, HIPAA-II, and HIPAA-III (Must submit these forms. If not applicable, enter “N/A” on the
forms and return)
PREPARED BY:
______________________________________________________________________
_______________________________________
Name & Title
Collect / Toll Free Phone Number
E-MAIL ADDRESS, if available:
E-HMDO.AS (11/00)
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